Unmet health care needs among pregnant women during COVID‐19 pandemic and its determinants in Kurdistan province, Iran: A cross‐sectional study

Abstract Background and Aims The aim of this study was to assess unmet needs for health care and its determinants during COVID‐19 pandemic among pregnant women in Iran. Methods This cross‐sectional study was performed among pregnant women in Kurdistan province in 2020 with a sample size of 800 people who were selected by multistage sampling method. Data were collected using a structured questionnaire that was completed through interviews. Also, multiple logistic regression was used to determine the relationship between independent variables and outcome variable. Statistical tests were performed using Stata software package. Results The highest unmet needs for health care were related to dental services with 66%, rehabilitation services with 58.6%, and psychological services with 43.2% and the lowest were related to hospital services with 12%, midwifery services with 15.6%, and physician visit services with 39.1%. The most important reasons for unmet needs for health care were fear of getting COVID‐19 and the cost of the services. The variables of age group and spouse education for physician visit services; age group for midwifery services; age group, education and employment status for dental services; age group, supplementary insurance and economic status for rehabilitation services; and age group and economic status for psychological services were significantly associated with unmet needs for health care (p < 0.05). Conclusion A significant percentage of health care needs of pregnant women was unmet, for which the fear of getting COVID‐19 and financial barriers were the main reasons.


| INTRODUCTION
In any society, health is considered as a prerequisite for sustainable development in which women have an irreplaceable role as the main axis of public health. 1 Pregnant women are one of the most vulnerable groups in any society. Receiving essential health care by this group is of special importance because they play a key role in the health of mother and child. 2 It is widely accepted that the use of health care during pregnancy will reduce morbidity and mortality of mothers and infants. In other words, access to and use of health care services by pregnant mothers are of the most important factors in improving pregnancy outcomes. [3][4][5] Understanding health needs, as well as unmet health needs and barriers to their use of health services, is an important key in developing strategies to improve the health of pregnant women.
One of the goals of health systems is to provide equal access to health care for people with equal needs. One way to measure equality of access to services is through reports of unmet needs for health care. 6 Unmet healthcare needs may lead to poorer health for people who have dropped out from healthcare services. Unmet needs are a significant driver in creating health inequalities and reflect health needs for which services are not provided. 7 Identifying the gap between "perceived health care needs" and "benefiting from health care" and finding the causes of this gap is very important to design targeted interventions to reduce this gap and improve access to health care services. 8 Access to health services is influenced by various factors such as gender, age, marital status, knowledge, attitude, education, health beliefs, financial status, insurance status, health services cost, quality of provided care, distance to health care provider, general health status, the severity of the disease and disability. [9][10][11] Crises, both natural and unnatural, can affect the pattern of health services use, the behavior of people and health care providers. [12][13][14] The crisis caused by COVID-19 pandemic is a global crisis and has led to the infection and death of millions of people in the world. In Iran, according to statistics, 7,237,156 people have been infected so far and 141,386 people have died as a result of this disease. 15 COVID-19 pandemic has affected the use of health services and has caused the shift of human resources and equipment of health sector towards the prevention, diagnosis, and treatment of this disease. 16 A survey by WHO found that the highest disruptions in providing health care services during COVID-19 were among low-income countries, and it was estimated that reducing basic maternal and child health interventions could result in more than one million child deaths. 17,18 People may not receive health services for fear of getting COVID-19 if they go to a health center or because of not having access to services due to lockdown and cancellation of or delay in providing nonemergency services. 16 Stress, social distance, and limitations due to the current situation can affect the pattern of need and benefit of pregnant women from health services as part of society. Identifying the needs and factors affecting the use of health services and unmet health care needs is very important to formulate and implement targeted policies and interventions. Based on the literature review, no study has ever been done on assessing unmet health needs and its causes among pregnant women, as a vulnerable part of society, during the COVID-19 crisis. In this regard, the present study was conducted to assess unmet health needs and their causes during the COVID-19 pandemic among pregnant women in Iran (Kurdistan Province).

| Study participants and sampling
This was a cross-sectional study. The study population included pregnant women in Kurdistan province in 2020, who were pregnant for at least 6 months. In the first stage, the sample size was determined 600 people using the following formula and taking into account p = 50% (benefiting from health services), d = 0.04 (accuracy rate) and α = 0.05 (type I error).
Since the clustering method was used for sampling; therefore, to increase the sampling accuracy, the design effect was set at 1.33 and the final sample size was 800 people. Multistage sampling was used for choosing the samples. First, Sanandaj and Mariwan counties were randomly selected among 10 counties of the province, and then within each county, the county center and its villages were selected.
In the next stage, 10 centers (five urban and five rural centers) were randomly selected by cluster random sampling from the comprehensive urban and rural health centers of each selected county. Then, among the pregnant women covered by each center, 40 pregnant women were randomly selected and after obtaining the addresses, a questionnaire was completed for them by a trained person by going to their door and through doing an interview.

| Data collection
The required information was collected through the Utilization of Health Services Questionnaire (UHS), which is a valid and reliable questionnaire developed by Iranian National Institute of Health Research. 6 The questionnaire consists of three parts: the first part covers demographic and background information including age, gender, occupation, education, employment status, type of basic insurance, supplementary insurance status and place of residence.
The second part includes the economic status of the household and the third part focuses on whether the person (pregnant mother) needed health services or not, then the type of need is determined and in the next stage, the question is asked on whether she received the required services or not. Finally, the reasons for not receiving the required services (the service was too expensive for us, the quality of service was low, there is no required medical specialty in this area, the waiting time was too long, it was far from my home, I did not have time, fear of getting COVID-19 disease) are clarified. The third section includes "Yes/No" questions. In this study, the need for health services was based on self-reporting of the pregnant mother (illness and perceived need). Unmet needs were needs that the person realized existed but was unable to meet. It should be noted that the reminder period for outpatient health services including visits of doctors, midwives, dentists, psychologists, and rehabilitators was considered the last 4 weeks and for inpatient services including hospitalization was the last 6 months.

| Statistical analysis
In this study, the asset index was applied to calculate the economic status. Using the principal composition analysis (PCA) method, first the variables that had the greatest impact on the variance of total variables were identified and then a new variable was created (SES) based on these variables. Using the mean of this variable, five quintiles were constructed that divided the population into five groups: very poor, poor, average, rich, and very rich. Multivariate logistic model, adjusted odds ratio, and confidence interval were used to determine the relationship between independent variables and the outcome variables (unmet health care needs). In the adjusted model, the variables that had p < 0.2 in the crude model were included in the model and other variables were removed from the model. All analyzes were performed in Stata 12.0 (Stata Corporation) and p < 0.05 was considered a statistical significance level.

| Ethical considerations
The ethics committee of Kurdistan University of Medical Sciences approved the protocol of the study (No. IR.MUK.REC.1399.246). The researchers explained the research goals and protocol to the participants before their inclusion in the study, and written informed consent was obtained from all eligible participants who were willing to participate in the study. Also, the highest ratio of received services was related to hospital services with 87.9% (73 people) and the lowest ratio was for dental services with 34.0% (48 people). In contrast, the highest and lowest proportion of unmet needs were related to dental services with 66% (93 people) and hospital services with 12% (10 people) (Table 1 and Figure 1). In addition, "fear of getting COVID-19 disease" and "cost of services" were reported as reasons for not using health services despite the need. For example, for dental services, 63% of people reported the cost of services and for inpatient services, 80% of people reported fear of getting COVID-19 as a barrier to using the required health services. It should be noted that in the present study, none of the pregnant mothers had given up receiving their required services due to lack of physical access, lack of time, low quality of services or lack of relevant specialist ( Table 1). Table 2 shows the determinants of unmet needs in the crude and adjusted model. In the crude model, the majority of variables were among the significant determinants of unmet needs. For instance, for physician visit services, women in the age group >35 years (odds ratio
In terms of dental services, women in higher age groups However, in the adjusted model after removing variables with p > 0.2, the variables of age group and spouse education for physician visit services; age group for midwifery services; age group, education and employment status for dental services; age group, supplementary insurance and economic status for rehabilitation services; and age group and economic status for psychological services were still significantly associated with unmet needs (p < 0.05).

| DISCUSSION
Unmet health care needs are a simple tool for monitoring access to healthcare services and the extent of inequalities in access to health services. Unmet health needs are the gap between the services needed and the services actually received. 19 The aim of this study was to assess the unmet health needs and their causes during the COVID-19 pandemic among pregnant women in Iran (Kurdistan province).  Waiting time Although basic health insurance organizations cover a huge percentage of the population in Iran, and according to statistics, more than 90% of the country's population has insurance, the country's insurance system has many challenges such as the number and type of services included in the insurance services package and depth of covering services costs. These issues have created a weakness in the efficiency of the insurance system in preventing households from facing catastrophic healthcare expenditures. 24 Also, the significant difference between the tariff rate of the private and public sectors is another problem for the country's health system. Basic insurance, if the patient refers to the private sector, does not cover this difference in the tariff rate and all costs must be paid by the patient. In Iran, dental, midwifery, rehabilitation, and psychological services are not covered by basic health insurance and the cost of these services must be paid by the patients out of pocket. 22,24,25 In Iran, most hospital services are provided by the public sector and most outpatient services (such as physician, and dentist visits as   were also more likely to have unmet health care needs. According to a study in India, women's level of education and household economic status were influential factors in the use of prenatal health care. 26

| STRENGTHS OF THE STUDY
This is the first study in Iran to calculate the unmet health care needs among pregnant women during the COVID-19 crisis.

| LIMITATIONS OF THE STUDY
In this study, information about perceived need and using health services was collected based on self-reporting of pregnant women and may be accompanied by a reminder error, although the research team tried to reduce this error by shortening the reminder period for outpatient services to 1 month and for inpatient services to 6 months.

| CONCLUSION
There is a deep gap between perceived need and receiving health services in the population of pregnant women; much of the perceived need for health services has been ignored. The main reasons for UNHC were "fear of getting COVID-19" and "services cost". Our